Receipt of Preventive Services After Oregon’s Randomized Medicaid Experiment

Published:October 20, 2015DOI:


      It is predicted that gaining health insurance via the Affordable Care Act will result in increased rates of preventive health services receipt in the U.S., primarily based on self-reported findings from previous health insurance expansion studies. This study examined the long-term (36-month) impact of Oregon’s 2008 randomized Medicaid expansion (“Oregon Experiment”) on receipt of 12 preventive care services in community health centers using electronic health record data.


      Demographic data from adult (aged 19–64 years) Oregon Experiment participants were probabilistically matched to electronic health record data from 49 Oregon community health centers within the OCHIN community health information network (N=10,643). Intent-to-treat analyses compared receipt of preventive services over a 36-month (2008–2011) period among those randomly assigned to apply for Medicaid versus not assigned, and instrumental variable analyses estimated the effect of actually gaining Medicaid coverage on preventive services receipt (data collected in 2012–2014; analysis performed in 2014–2015).


      Intent-to-treat analyses revealed statistically significant differences between patients randomly assigned to apply for Medicaid (versus not assigned) for 8 of 12 assessed preventive services. In intent-to-treat analyses, Medicaid coverage significantly increased the odds of receipt of most preventive services (ORs ranging from 1.04 [95% CI=1.02, 1.06] for smoking assessment to 1.27 [95% CI=1.02, 1.57] for mammography).


      Rates of preventive services receipt will likely increase as community health center patients gain insurance through Affordable Care Act expansions. Continued effort is needed to increase health insurance coverage in an effort to decrease health disparities in vulnerable populations.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bailey S.R.
        • OʼMalley J.P.
        • Gold R.
        • Heintzman J.
        • Likumahuwa S.
        • DeVoe J.E.
        Diabetes care quality is highly correlated with patient panel characteristics.
        J Am Board Fam Med. 2013; 26: 669-679
        • Freeman J.D.
        • Kadiyala S.
        • Bell J.F.
        • Martin D.P.
        The causal effect of health insurance on utilization and outcomes in adults: a systematic review of U.S. studies.
        Med Care. 2008; 46: 1023-1032
        • Buchmueller T.C.
        • Grumbach K.
        • Kronick R.
        • Kahn J.G.
        The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature.
        Med Care Res Rev. 2005; 62: 3-30
        • DeVoe J.
        • Fryer G.
        • Phillips R.
        • Green L.
        Receipt of preventive care among adults: insurance status and usual source of care.
        Am J Public Health. 2003; 93: 786-791
        • Duru O.K.
        • Vargas R.B.
        • Kermah D.
        • Pan D.
        • Norris K.C.
        Health insurance status and hypertension monitoring and control in the United States.
        Am J Hypertens. 2007; 20: 348-353
        • McMorrow S.
        • Kenney G.M.
        • Goin D.
        Determinants of receipt of recommended preventive services: implications for the Affordable Care Act.
        Am J Public Health. 2014; 104: 2392-2399
        • Cowburn S.
        • Carlson M.
        • Lapidus J.
        • Heintzman J.
        • Bailey S.
        • DeVoe J.
        Insurance continuity and human papillomavirus vaccine uptake in Oregon and California federally qualified health centers.
        Am J Public Health. 2014; 104: e71-e79
        • Holden C.D.
        • Chen J.
        • Dagher R.K.
        Preventive care utilization among the uninsured by race/ethnicity and income.
        Am J Prev Med. 2015; 48: 13-21
      1. Kaiser Family Foundation. "The Medicaid program at a glance," Publication 7235-05; Published 2012. Accessed June 10, 2015.

      2. Kaiser Family Foundation. How is the ACA impacting Medicaid enrollment? Published 2014. Accessed June 10, 2015.

        • Abraham J.M.
        How might the Affordable Care Actʼs coverage expansion provisions influence demand for medical care?.
        Milbank Q. 2014; 92: 63-87
        • Ku L.
        • Jones K.
        • Shin P.
        • Bruen B.
        • Hayes K.
        The statesʼ next challenge—securing primary care for expanded Medicaid populations.
        N Engl J Med. 2011; 364: 493-495
        • Schoen C.
        • Hayes S.L.
        • Radley D.C.
        • Collins S.R.
        Access to primary and preventive health care across states prior to the coverage expansions of the Affordable Care Act.
        Issue Brief (Commonwealth Fund). 2014; 17: 1-14
        • Clark C.R.
        • Soukup J.
        • Riden H.
        • et al.
        Preventive care for low-income women in Massachusetts post-health reform.
        J Womens Health (Larchmt). 2014; 23: 493-498
        • Okoro C.A.
        • Dhingra S.S.
        • Coates R.J.
        • Zack M.
        • Simoes E.J.
        Effects of Massachusetts health reform on the use of clinical preventive services.
        J Gen Intern Med. 2014; 29: 1287-1295
        • Keating N.L.
        • Kouri E.M.
        • He Y.
        • West D.W.
        • Winer E.P.
        Effect of Massachusetts health insurance reform on mammography use and breast cancer stage at diagnosis.
        Cancer. 2013; 119: 250-258
        • Kolstad J.
        • Kowalkski A.E.
        The impact of health care reform on hospital and preventive care: evidence from Massachusetts.
        J Public Econ. 2012; 96: 909-929
        • Van Der Wees P.J.
        • Zaslavsky A.M.
        • Ayanian J.Z.
        Improvements in health status after Massachusetts health care reform.
        Milbank Q. 2013; 91: 663-689
        • Allen H.
        • Baicker K.
        • Finkelstein A.
        • Taubman S.
        • Wright B.J.
        • Group O.H.S.
        What the Oregon health study can tell us about expanding Medicaid.
        Health Aff (Millwood). 2010; 29: 1498-1506
        • Baicker K.
        • Taubman S.L.
        • Allen H.L.
        • et al.
        The Oregon experiment—effects of Medicaid on clinical outcomes.
        N Engl J Med. 2013; 368: 1713-1722
        • Finkelstein A.
        • Taubman S.
        • Wright B.
        • et al.
        The Oregon Health Insurance Experiment: evidence from the first year.
        Q J Econ. 2012; 127: 1057-1106
        • Taubman S.L.
        • Allen H.L.
        • Wright B.J.
        • Baicker K.
        • Finkelstein A.N.
        Medicaid increases emergency-department use: evidence from Oregonʼs Health Insurance Experiment.
        Science. 2014; 343: 263-268
      3. Oregon Division of Medical Assistance Programs. OHP Standard reservation list—final report. Published 2008. Accessed June 10, 2015.

      4. Oregon Department of Human Services, Division of Medical Assistance Programs. Oregon Health Plan annual report: Medicaid and State Childrenʼs Health Insurance Program Section 1115(a) Medicaid demonstration extension. Published 2008. Accessed June 2, 2015.

        • Baicker K.
        • Taubman S.L.
        • Allen H.L.
        • et al.
        The Oregon experiment—effects of Medicaid on clinical outcomes.
        N Engl J Med. 2013; 368: 1713-1722
      5. National Association of Community Health Centers. United States Health Center Fact Sheet. Published 2012. Accessed June 10, 2015.

      6. The White House. The Obama Administration and community health centers. Washington, DC. Published 2012. Accessed June 10, 2015.

        • Devoe J.E.
        • Gold R.
        • McIntire P.
        • Puro J.
        • Chauvie S.
        • Gallia C.A.
        Electronic health records vs Medicaid claims: completeness of diabetes preventive care data in community health centers.
        Ann Fam Med. 2011; 9: 351-358
        • Devoe J.E.
        • Gold R.
        • Spofford M.
        • et al.
        Developing a network of community health centers with a common electronic health record: description of the Safety Net West Practice-based Research Network (SNW-PBRN).
        J Am Board Fam Med. 2011; 24: 597-604
        • Devoe J.E.
        • Sears A.
        The OCHIN community information network: bringing together community health centers, information technology, and data to support a patient-centered medical village.
        J Am Board Fam Med. 2013; 26: 271-278
      7. USDHHS, CDC, National Center for Chronic Disease Prevention and Health Promotion. Registry Plus, a suite of publicly available software programs for collecting and processing cancer registry data. Published 2010. Accessed June 10, 2015.

        • Sussman J.B.
        • Hayward R.A.
        An IV for the RCT: using instrumental variables to adjust for treatment contamination in randomised controlled trials.
        BMJ. 2010; 340: c2073
      8. Center for Medicaid and Medicare Services. 2011-2012 eligible professional clinical quality measures (CQMs). Published 2012. Accessed June 10, 2015.

        • Heintzman J.
        • Bailey S.R.
        • Hoopes M.J.
        • et al.
        Agreement of Medicaid claims and electronic health records for assessing preventive care quality among adults.
        J Am Med Inform Assoc. 2014; 21: 720-724
      9. National Committee for Quality Assurance (NCQA). HEDIS 2013: technical specifications for physician measurement. Washington, DC: 2013.

        • Heckman J.
        Dummy endogenous variables in a simultaneous equation system.
        Econometrica. 1978; 46: 931-959
        • Greene W.
        Econometric Analysis.
        5th ed. Prentice Hall, Upper Saddle River, NJ2003
        • Williams R.L.
        A note on robust variance estimation for cluster-correlated data.
        Biometrics. 2000; 56: 645-646
        • Rogers W.
        Regression standard errors in clustered samples.
        Stata Tech Bull. 1994; 3: 19-23
        • Baicker K.
        • Finkelstein A.
        The effects of Medicaid coverage—learning from the Oregon experiment.
        N Engl J Med. 2011; 365: 683-685
      10. Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation. Community health centers: a 2012 profile and spotlight on implications of state Medicaid expansion decisions. Published September 2014. Accessed June 10, 2015.

        • Bowling A.
        Mode of questionnaire administration can have serious effects on data quality.
        J Public Health (Oxf). 2005; 27: 281-291
        • Choi B.C.
        • Pak A.W.
        A catalog of biases in questionnaires.
        Prev Chronic Dis. 2005; 2: A13
        • Tisnado D.M.
        • Adams J.L.
        • Liu H.
        • et al.
        What is the concordance between the medical record and patient self-report as data sources for ambulatory care?.
        Med Care. 2006; 44: 132-140
        • Decker S.L.
        In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help.
        Health Aff (Millwood). 2012; 31: 1673-1679
        • Shi L.
        • Stevens G.D.
        The role of community health centers in delivering primary care to the underserved: experiences of the uninsured and Medicaid insured.
        J Ambul Care Manage. 2007; 30: 159-170
        • Bruen B.K.
        • Ku L.
        • Lu X.
        • Shin P.
        No evidence that primary care physicians offer less care to Medicaid, community health center, or uninsured patients.
        Health Aff (Millwood). 2013; 32: 1624-1630
        • Goldman L.E.
        • Chu P.W.
        • Tran H.
        • Romano M.J.
        • Stafford R.S.
        Federally qualified health centers and private practice performance on ambulatory care measures.
        Am J Prev Med. 2012; 43: 142-149
        • Angier H.
        • Hoopes M.
        • Gold R.
        • et al.
        An early look at rates of uninsured safety net clinic visits after the Affordable Care Act.
        Ann Fam Med. 2015; 13: 10-16
      11. National Association of Community Health Centers. A sketch of community health centers. Chart book 2014. Accessed June 10, 2015.

        • Heintzman J.
        • Marino M.
        • Hoopes M.
        • et al.
        Using electronic health record data to evaluate preventive service utilization among uninsured safety net patients.
        Prev Med. 2014; 67: 306-310
        • Gold R.
        • DeVoe J.
        • Shah A.
        • Chauvie S.
        Insurance continuity and receipt of diabetes preventive care in a network of federally qualified health centers.
        Med Care. 2009; 47: 431-439
        • DeVoe J.E.
        • Tillotson C.J.
        • Lesko S.E.
        • Wallace L.S.
        • Angier H.
        The case for synergy between a usual source of care and health insurance coverage.
        J Gen Intern Med. 2011; 26: 1059-1066
        • Gold R.
        • DeVoe J.E.
        • McIntire P.J.
        • Puro J.E.
        • Chauvie S.L.
        • Shah A.R.
        Receipt of diabetes preventive care among safety net patients associated with differing levels of insurance coverage.
        J Am Board Fam Med. 2012; 25: 42-49
        • Bailey S.R.
        • OʼMalley J.P.
        • Gold R.
        • Heintzman J.
        • Marino M.
        • DeVoe J.E.
        Receipt of diabetes preventive services differs by insurance status at visit.
        Am J Prev Med. 2015; 48: 229-233
      12. USDHHS. Affordable Care Act rules on expanding access to preventive services for women. Published 2013. Accessed June 10, 2015.

      13. Kaiser Family Foundation. Adults who remained uninsured at the end of 2014. January 29, 2015. Accessed June 10, 2015.